Abstract

BackgroundThe Quality and Outcomes Framework (QOF) has had a major impact on chronic care provision in British general practice. Various countries are looking at whether a similar initiative could be used in their primary care systems. An extensive quality indicator system like the QOF does not exist in German general practice. AimTo describe and explore the views of German general practitioners (GPs) on the clinical indicators of the QOF. MethodsQualitative study based on focus group discussions and a framework approach for data analysis. Fifty-four German GPs were involved in seven focus groups in German primary care practices. Results German GPs expressed mixed views regarding the validity of the QOF clinical indicators to measure the quality of primary care. Most thought that these indicators covered areas that were relevant for German general practice and which were only partially covered by German quality initiatives. Participants had mixed opinions regarding linking pay and performance. Many thought that in deprived areas it would be difficult to achieve targets. Exception reporting would make achieving these targets easier, however, some believed it could lead to manipulation of figures. Many GPs saw QOF clinical indicators as a helpful structure, yet feared that introducing something similar would increase the administrative workload and be a threat to patient-centred care. Many participants were anxious that a QOF-like system could be influenced by sickness funds or the pharmaceutical industry. A few feared data protection problems if such a system were to be implemented. Several GPs expressed concerns on who would set and control such quality initiatives, feared for their autonomy and expected that in the future similar systems would be imposed upon them.ConclusionsParticipating German GPs had various concerns regarding the QOF clinical indicators and the idea of implementing a system like the QOF in German primary care. These concerns were mainly related to the validity of the indicators, the link between pay and performance, structured care versus patient centredness and the fear of external influences.

Keywords

Introduction

Improving the quality of medical care has become a
major issue for all healthcare systems.1 However, there
are many barriers to changing clinicians’ behaviour
and most initiatives to improve patient care have had
only limited or mixed effects.2,3 From that point of
view the QOF seems an exception. The QOF is a pay
for performance system, consisting of clinical, organisational
and other indicators. The clinical indicators
represent the main part of the framework and cover
problem areas ranging from coronary heart disease
and depression to obesity and smoking. The QOF was
introduced in theUK in April 2004 and although it is a
voluntary scheme, 99.8% of UK practices participate.
Average achievement has consistently been over 90%,
with a mean score of 96.8% in 2007 to 2008.4,5 What
does this mean in relation to quality improvement in
UK primary care? Several early studies on the QOF
compared data from just before and just after its
introduction and suggested that the framework had
improved the quality of care for conditions like asthma,
diabetes and heart disease.6–10 Other early research
indicated that the differences in QOF achievement
between affluent and deprived areas were small and
that the QOF may have diminished health inequalities.
9,11–15 However, more recent studies suggested
more negative outcomes. The QOF seemed to have
improved the quality of chronic care, but the pace of
improvement was not sustained once quality goals
were reached. Further, the QOF seemed to have had a
negative effect on the quality of care of conditions
which were not included in the QOF and may have
reduced continuity of care.16 Finally, another recent
study indicated that the scheme failed to capture a
significant proportion of diabetic patients and as such
may not have been as efficient in reducing inequalities
in diabetes care as initially was hoped.17

Despite these recent concerns the QOF is seen as
a major innovation amongst quality improvement
measures and various countries are looking at whether a similar initiative could be used in their primary care
systems.18,19 At an international level there is some
evidence that the development of quality indicators
follows a similar direction and that a transfer of such
indicators between countries is possible, albeit with
caution.20–22

In German general practice there are quality initiatives
such as clinical guidelines and a few disease
management programmes (DMPs) in which individual
patients can opt to participate.23 However, at practice
level, an extensive quality indicator system like the
QOF does not exist and as such there seems to be a
‘quality indicator gap’. Before such a system could be
developed or transferred to German primary care it
would be necessary to know the views of the clinicians
who would be expected to use it. Therefore the aim of
our study was to describe and explore the views of
German GPs on the clinical indicators of the QOF.

Methods

Preparation and planning

We based our methodology on a phenomenological
approach. There were two main reasons for this choice.
Firstly, we wanted to describe and explore the subjective
views of German GPs; secondly, we recognised
our restrictions, especially in relation to manpower
and resources.

In consequence we wanted to use focus groups to
collect data with the aim of capturing opinions and to
using interaction to spark new ideas. We decided to
use the full set of QOF clinical indicators (2006 version)
as a guide for our participants, as this set forms the
main part of the QOF and represents the key principles.
We thought that the whole QOF would be too
long and less relevant to German GPs and therefore
not feasible to discuss in a focus group. The aforementioned
guide was translated into German. We also
developed a semi-structured topic guide.

First we pilot tested our focus group procedure by
organising two sessions involving a total of seven GPs
known to the research department. Based on these we
slightly adapted the topic guide, while the QOF clinical
indicators guide remained the same.

Sample

Our sampling strategy was to recruit participants via
German GP ‘quality circles’ (peer review groups).
These peer review groups consist of GPs who meet
up approximately once every two months. At each of
their meetings they discuss clinical topics or practice
issues as a means of quality improvement and continuing
professional development (CPD). As we wanted
to collect the views of a broad spectrum of German
GPs, we phoned the coordinating GPs of urban and
rural peer review groups in a wide geographic area in
the northwest of Germany. Those coordinating GPs
who were interested in the project were sent an email
or a fax with extensive information regarding the
study. In total we contacted 15 of these coordinating
doctors and seven of their peer review groups agreed
to participate. Seven focus groups with 54 participants
(34 male and 20 female German GPs), covering practices
in the north-western part of Germany, were
conducted during the period from June 2008 to
November 2008. Focus groups included six to 11
participants and involved GPs from urban and rural
practices.

Data collection and analysis

Coordinators of the peer review groups determined
where the focus groups took place, usually in a
primary care practice. At the start of each session
every participant received the QOF clinical indicators
guide and everyone was given ample time to read and
study this before the focus group discussion. One
researcher with extensive experience as a GP in British
primary care (HVDH) moderated the sessions using
the pilot tested semi-structured topic guide. Duration
of the focus groups was between one and a half and
two hours. All discussions were audiotaped and transcribed
verbatim.

In line with the methodology we applied a framework
approach for analysis.24 Two researchers (HVDH
and SH) independently familiarised themselves with
the data and coded the transcribed interviews (using
Maxqda 2007 data analysis software, inductive mode)
to identify a thematic framework.25 They matched
their provisional frameworks, this matched version
was shared with the other two researchers (PM and
EHP), and all were involved in finalising the framework.
The coordinating GPs of the participating peer
review groups were invited to provide feedback on this analysis and no alterations were required. Finally, all
four researchers took part in drafting the paper which,
via iterative discussion over many weeks, led to a
consensus article. A qualified medical translator translated
quotes from German into English.

Results

Our focus groups revealed four main areas of concern
related to the idea of implementing a system like
the QOF in German primary care: validity of quality
assessment in primary care, implications of linking
pay and performance, indicator orientated care versus
patient centredness and fear of external influences.

Validity of quality assessment in
primary care

German GPs expressed mixed views on whether the
QOF clinical indicators captured quality in primary
care. Many saw the collection of QOF clinical indicators
as a ‘set of clinical guidelines’. Although most
GPswere positive about clinical guidelines, they thought
these had limitations in covering quality, especially
related to the care of patients with multiple problems
and conditions.

‘It’s a big problem that there are many elderly patients,
who have coronary heart disease as well as asthma, and
then diabetes too, and perhaps they are also obese or
depressed or whatever, and then I am sitting there and I
have to get through four of such schemes (QOF), that is
really too much, no way.’ (Focus Group (FG) D, GPA, 16)

The GPs also had mixed opinions on whether the
‘QOF percentages’ (the proportion of patients for
whom a predefined target was met) could be used to
measure quality. Some felt that their use was a good
approach to making the essentials quantifiable. However,
many participants thought that these percentages
would shift the focus too much towards easy to
measure parameters.

‘And the risk is, in line with public health interests, that
more and more those diseases are measured, or treated, or
are in the spotlight, which can be measured with hard
data! Since these can easily be processed into some
programmes, you can simply draw straight lines, and
you also can define demands or make adjustments on
pay and so on ...’ (FG H, GP A, 76)

In general, GPs saw timeframes as good tools for
measuring quality. It was noted that in the QOF
intervals of 15 months were often used. Many considered
this an odd time span, questioned the statistical
and practical value and thought it could promote minimal standards. Some believed that the interval
length should depend on the weight of the parameter.

Most GPs thought that the QOF clinical indicators
covered clinical areas that were relevant for German
primary care. Many thought that they did not cover
German general practice in full. Several thought that a
wide range of areas, from low back pain to unspecific
problems like ‘dizziness’, were missing and some
expressed the opinion that there was too much emphasis
on managing disease as opposed to health
promotion.

Most participants mentioned that the QOF clinical
indicators had some overlap with German DMPs but
thought that the DMPs were more bureaucratic and
covered a much smaller area of primary care. Finally,
several GPs mentioned that they had first been sceptical
about the implementation of the DMPs, but
thought thatwith time they had become more efficient
in using them, and now also saw some value in this
system.

Implications of linking pay and
performance

On being asked what would be an incentive to use a
system like the QOF, many GPs mentioned payment.
There was debate regarding how much extra money
would be required for these participants to use such a
system. However, several participants felt ashamed of
accepting pay for performance and had doubts regarding
the principle. They mentioned that they would
also use a scheme like the QOF if they were convinced
that it was beneficial for their patients, in line with
professional guidance and restricted to a few relevant
key issues (Box 1).

Many GPs had doubts whether practices could be
compared based on QOF figures and thought that GPs
in deprived areas would find it hard to achieve targets,
despite putting in a lot of effort.

‘I’ll give Aspirin tomypatient with coronary heart disease,
but I cannot influence it, for example, when HbA1c is used
as a parameter for diabetic patients. If I’ve got a certain
practice population, I can break my back, but I’ll never get
anywhere. That’s the problem.’ (FG C, GP A, 88)

As such they considered the link between pay and
performance to be unfair.

‘Exception reporting’ is the procedure in the QOF
that allows certain patients to be excluded from the
percentages (for example, patients who clearly express
that they do not want indicated medication or tests).
This procedure was discussed in the focus groups.
Many participants felt that exception reporting would
make the link between pay and performance more
acceptable, but some feared that it could lead to manipulation
of figures, for example by excluding the
‘non-compliant patients’.

Indicator orientated care versus
patient centredness

Many GPs saw the QOF scheme as a helpful structure
for systematic care and professional reflection, and as
a potential quality marker. Most participants wanted
to receive feedback on their treatment, as long as itwas
adequate and timely, and for that reason wouldwelcome
a system like the QOF. They considered this to be
missing in their current system.

‘The positive point regarding these systems is that one gets
a reflection on the job done, and also obtains figures for
comparison with other practices.’ (FG G, GP B, 155)

‘If I get feedback that I have improved, that I do well, ...
that I ampositively motivated, that I amconvinced of the
purpose, that it is well delivered, well, then I think it would
be very valuable.’ (FG I, GP C, 128)

Some thought that a lot of work related to the QOF
clinical indicators could be delegated to the ‘practice
assistants’, making their job more interesting while
at the same time saving some of the doctors’ time.
However, the majority feared that theQOFwould lead
to an increase in administrative workload. Related to
this, a lot of GPs expressed a dislike for working with
percentages and statistics. Many recognised information
technology (IT) as the key factor in addressing
this issue yet felt that the current practice IT systems in
Germany were limited and that major alterations
would be required in order to be able to use a system
like the QOF.

Many participants saw the indicator orientation as a
threat to patient-centred care and worried that it
could lead to a loss of patient orientation, to ‘tunnel
vision’ and to a loss of use of GP intuition. This could go so far that non-compliant patients would be seen as
‘the enemy’ of their performance figures (Box 2).

Fear of external influences

Several GPs were concerned about who would set and
control quality initiatives like the QOF and feared for
their autonomy. Many participants did not like the
idea that QOF data could be accessed and collected by
a third party, such as a health authority. Some were
concerned that quality indicators could be manipulated
by these third parties, for example the pharmaceutical
industry or the sickness funds. Related to this, a few
GPs thought there would be data protection issues if a
system like the QOF were implemented in Germany
(Box 3).

Finally, various GPs expected that in the future
similar systems would be imposed upon them.

‘When we get such systems, once more you get the feeling
that there is again such a bureaucratic system, which
demands issues and requires fulfilling these demands,
what you don’t want to do ... However, I think it is always
such a dilemma; on the one hand it is obviously good to
have structured care, on the other hand: when this
suppresses everything, then it won’t lead to anything.’
(FG G, GP I, 158)

Discussion

Main findings

Most German GPs thought that the QOF clinical
indicators covered areas that were relevant for German
general practice and that these were only partially
covered by German quality initiatives. Most participants
expressed ambiguous feelings regarding the
QOF clinical indicators and the idea of implementing
a system like the QOF.

Strengths and weaknesses of the
study

A particular strength of the study is that for the first
time German GPs have been asked to provide their
views on the QOF clinical indicators. Another strong
point is the relatively large number of GPs, rural and
urban, that participated in the focus groups.

The study has several limitations. First the participants
were recruited from peer review groups.As these
groups consist of GPs interested in quality improvement
and CPD, they may be more positive about
quality indicators than GPs who are not participants,
which could have caused bias. Also, they were GPs
from the north-western part of Germany and views of
colleagues in the south and east may be different.
Finally, the views of the GPs were expressed based on
their assessment of the indicators and this may not be
the same as what they would do in practice.

Comparison with existing literature

At the introduction of the QOF in 2004 British GPs
questioned whether the scheme would improve the
quality of care and feared especially a reduction in
their autonomy, less patient centredness, a reduction
in the continuity of care and an increased administrative
workload. Also it was expected that the framework
would show a poor performance in deprived
areas and that it might lead to manipulation of figures.
However, subsequent research suggested that theQOF
had improved the quality of chronic care, although this did not improve further once quality targets had
been achieved. The scheme seemed to have had a
negative impact on the quality of care of nonincentivised
conditions and it may have reduced the
continuity of care. After using the framework for
several years UK GPs expressed the view that QOF
had changed the way of working in their practices. For
example, they thought that practice nurses had a more
central role in chronic care and that care provisionwas
more fragmented. Also it was noticed that at times
there was a tension between the patient’s and the
QOF’s agendas. The feared extra administrative workload,
loss of autonomy, problems related to poor
performance in deprived areas and the risk of manipulation
of figures did not seem to have materialised.
6–17,26–29

Many concerns from British GPs before the introduction
of the QOF were similar to those identified in
this study. In contrast, this research project revealed
some differences from the findings of the literature
around QOF. For example many German GPs feared
the influence of third parties, like the pharmaceutical
industry or sickness funds, and some mentioned data
protection problems as an issue.

Implications for clinicians and policy
makers

This study has provided some insight related to what
German GPs think regarding QOF clinical indicators.
As these indicators were thought to be relevant and as
there seemed to be a ‘German quality indicator gap’,
one could consider whether certain parts of the QOF
clinical indicators could be used in German primary
care. However, the focus groups revealed that there
were several areas of concern related to the idea of
implementing a system like the QOF.

Some of these concerns have not been mentioned
before in the literature in relation to the QOF and
perhaps are specific to Germany, for example concerns
related to fear of the influence of the pharmaceutical
industry. Related to this the specific structure of the
German healthcare system needs to be taken into
account with different players, such as GPs, sick funds
and the industry representing different interests. Other
concerns were similar to previous British ones, for
example those related to the expected underperformance
in deprived areas. Several of these British worries have
not materialised in the UK, but that does not necessarily
have to be the case in Germany.17,18 Therefore if
one were to consider implementing a system like the
QOF in Germany, it would seem important to take all
of the identified concerns seriously and to take all of
them into account. Perhaps most worrying was that
several German GPs expressed concerns regarding
who would set and control the quality initiatives and worried that these would be imposed upon them. It
appears important to address this matter, for example
by organising meetings involving both policy makers
and clinicians, to try and overcome differences around
these initiatives. After that, if one still wanted to follow
a similar direction as the QOF, one could think about
piloting similar schemes in a few GP practices before
implementing them on a wider scale, or one could
even consider developing a ‘local QOF’ to address
local concerns.4

Future research

What would be the views of German patients regarding
a system like the QOF? This question could not be
answered in this study. Limited information exists
regarding the views of British patients on the QOF. A
recent study showed that British patients and their
GPs had different views on the depression questionnaires
used in QOF.30 It seems important to get the
views of German patients on such systems if these are
considered for development or implementation, for
example by inviting German patient groups to bring
forward their ideas on priority subjects.

Overall the debate on quality indicators forGerman
primary care has only just started and more research is
required regarding the development and implementation
of quality indicator systems in German general
practice.31,32 This paper may make a small contribution
to this debate.

Acknowledgements

We thank all participants for their cooperation. Special
thanks go to T Jones for his support, to S Friedrich and
M Ferna´ndez-Belver for their help related to the
translations and toD Lawrence for secretarial assistance.

Funding

This work was done at the Institute of General Practice
of Hanover Medical School, which is state funded.

Ethical Approval

Received from the Ethics Committee of Hanover
Medical School.

Peer Review

Not commissioned; externally peer reviewed.

Conflicts of Interest

None.

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